Update on pathogenesis of infective endocarditis

Histologic and bacteriologic findings in valvular endocarditis of slaughter-age pigs

Endocarditis lesions from 117 slaughter pigs were examined pathologically and etiologically in addition to 90 control hearts with cardiac valves. Lesions were located on the valves; however, the lesions had extended to the walls in 21 cases (18%). Lesions predominated on the mitral valve (59%). A total of 28 cases, from which no growth was obtained or a contamination flora was grown, were screened by fluorescence in situ hybridization (FISH) for bacteria (general bacterial probe) and probes specific for Streptococcus suis and Erysipelothrix rhusiopathiae, respectively. Using FISH, an additional 10 cases of endocarditis due to S. suis and E. rhusiopathiae were disclosed. Within lesions, streptococci predominated (53%) followed by E. rhusiopathiae (30%). Distinct features of both the lesions and the shape and localization of bacterial colonies were related to streptococci and E. rhusiopathiae. The propensity for streptococci to be localized on more than 1 valve in single hearts may be because S. suis-infected pigs tend to have been infected for a longer period compared with E. rhusiopathiae. Mineralization of endocarditis lesions was significantly associated with infection by streptococci, and was seen in 71% of the cases, whereas it was present in only 28% of lesions caused by E. rhusiopathiae. In addition, areas with mineralization were significantly correlated to the presence of a granulomatous reaction. Granulomatous endocarditis is likely a result of a foreign body reaction due to dystrophic mineralization. Local proliferation of valvular endothelial cells, found in 9 hearts in the current study, may increase the risk of developing thrombosing endocarditis in pigs.

Endocarditis-associated brain lesions in slaughter pigs

Left-sided valvular endocarditis (LSVE) is a common finding in slaughter pigs. The lesion is often associated with renal thromboembolism, but information on embolization to other organs is sparse. This study focuses on the presence and type of endocarditis-associated brain lesions (EABLs). The brains of 20 slaughter pigs with spontaneously arising LSVE and 11 controls were examined by sectioning half of a formalin-fixed brain into 4mm slices for histological examination. The aetiology of the endocarditis was determined by bacteriological and, in some cases, by fluorescence in-situ hybridization examinations. These examinations identified 11 cases of Streptococcus suis, six cases of Erysipelothrix rhusiopathiae, one Streptococcus spp. and two cases that remained aetiologically undetermined. One of the S. suis cases had a dual infection with S. suis in the aortic valve lesions and Streptococcus dysgalactiae subsp. equisimilis in the atrioventricular valve lesions. Renal infarcts were present in eight cases. Focal encephalitis was found in 12 cases, with the number of lesions ranging from one to 11. Most pigs had less than four microscopical lesions. Acute lesions were characterized by focal microabscesses without observable bacteria. Chronic lesions were characterized by astrocytosis and focal accumulation of mononuclear leucocytes. An infarct was observed in one animal. Perivascular inflammation was seen in 14 cases, mostly as two or three lesions, while focal leptomeningitis was found in eight cases. EABLs are therefore common in slaughter pigs with LSVE. The number of lesions per animal is small, which may explain the limited attention paid to this sequela of LSVE. EABLs have rarely been reported in domestic animals and mostly in patients with neurological signs. The frequent occurrence of EABLs in slaughter pigs suggests that this pathology should be investigated in other animal species with LSVE.

Pathology and pathogenesis of infective endocarditis in native heart valves

Infective endocarditis is an endovascular microbial infection of cardiovascular structures, including large intrathoracic vessels and intracardiac foreign bodies. The characteristic lesions consist of vegetations composed of platelets, fibrin, microorganisms, and inflammatory cells, as well as leaflet disruption. The commonly accepted pathogenetic theory is herein reported, from endothelial injury with deposition of noninfective sterile thrombotic vegetations to transient bacteremia with microorganism adhesion (injury-thrombus-infection theory). This review addresses the pathology of native valve endocarditis, including local (valvular and perivalvular destruction) and distal (embolism, metastatic infection, and septicemia) complications. Old and new cardiac conditions and patients at risk, predisposing to the occurrence of infective endocarditis, are then discussed. Particular emphasis is given to hidden bicuspid aortic valve and the need of early carrier identification for prophylaxis.